SummaryBenchmarks FullSet 2016

SUMMARY BENCHMARKS FOR PREFERRED
PRACTICE PATTERN GUIDELINES

TABLE OF CONTENTS
Summary Benchmarks for Preferred Practice Pattern Guidelines
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Glaucoma
Primary Open-Angle Glaucoma (Initial Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Primary Open-Angle Glaucoma (Follow-up Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Primary Open-Angle Glaucoma Suspect (Initial and Follow-up Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Primary Angle Closure (Initial Evaluation and Therapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
4
5
6
Retina
Age-Related Macular Degeneration (Initial and Follow-up Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Age-Related Macular Degeneration (Management Recommendations) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Diabetic Retinopathy (Initial and Follow-up Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Diabetic Retinopathy (Management Recommendations) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Idiopathic Epiretinal Membrane and Vitreomacular Traction (Initial Evaluation and Therapy) . . . . . . . . . . . . . . . . . . . . . . . . . 11
Idiopathic Macular Hole (Initial Evaluation and Therapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration

(Initial and Follow-up Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Retinal and Ophthalmic Artery Occlusions (Initial Evaluation and Therapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Retinal Vein Occlusions (Initial Evaluation and Therapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Cataract/Anterior Segment
Cataract (Initial and Follow-up Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Cornea/External Disease
Bacterial Keratitis (Initial Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bacterial Keratitis (Management Recommendations) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Blepharitis (Initial and Follow-up Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conjunctivitis (Initial Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conjunctivitis (Management Recommendations) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Corneal Ectasia (Initial Evaluation and Follow-up) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Corneal Edema and Opacification (Initial Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Corneal Edema and Opacification (Management Recommendations) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dry Eye Syndrome (Initial Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dry Eye Syndrome (Management Recommendations) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
19
20
21
22
23
24
25
26
27
Pediatric Ophthalmology/Strabismus
Amblyopia (Initial and Follow-up Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Esotropia (Initial and Follow-up Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Exotropia (Initial and Follow-up Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Refractive Management/Intervention
Keratorefractive Surgery (Initial and Follow-up Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2016 American Academy of Ophthalmology
October 2016
aao.org
SUMMARY BENCHMARKS FOR

PREFERRED PRACTICE PATTERN GUIDELINES
Introduction
These are summary benchmarks for the Academys
Preferred Practice Pattern (PPP) guidelines. The
Preferred Practice Pattern series of guidelines has
been written on the basis of three principles.
Each Preferred Practice Pattern should be clinically
relevant and specific enough to provide useful
information to practitioners.
Each recommendation that is made should be given
an explicit rating that shows its importance to the
care process.
Each recommendation should also be given an
explicit rating that shows the strength of evidence
that supports the recommendation and reflects the
best evidence available.
Preferred Practice Patterns provide guidance
for the pattern of practice, not for the care of a
particular individual. While they should generally
meet the needs of most patients, they cannot possibly
best meet the needs of all patients. Adherence to
these Preferred Practice Patterns will not ensure a
successful outcome in every situation. These practice
patterns should not be deemed inclusive of all proper
methods of care or exclusive of other methods of
care reasonably directed at obtaining the best results.
It may be necessary to approach different patients
needs in different ways. The physician must make the
ultimate judgment about the propriety of the care of
a particular patient in light of all of the circumstances
presented by that patient. The American Academy
of Ophthalmology is available to assist members in
resolving ethical dilemmas that arise in the course of
ophthalmic practice.
The Preferred Practice Pattern guidelines are not
medical standards to be adhered to in all individual
situations. The Academy specifically disclaims any
and all liability for injury or other damages of any kind,
from negligence or otherwise, for any and all claims
that may arise out of the use of any recommendations
or other information contained herein.
For each major disease condition, recommendations
for the process of care, including the history, physical
exam and ancillary tests, are summarized, along with
major recommendations for the care management,
follow-up, and education of the patient. For each
PPP, a detailed literature search of PubMed and the
Cochrane Library for articles in the English language

is conducted. The results are reviewed by an expert
panel and used to prepare the recommendations,
which are then given a rating that shows the strength
of evidence when sufficient evidence exists.
To rate individual studies, a scale based on the
Scottish Intercollegiate Guideline Network (SIGN) is
used. The definitions and levels of evidence to rate
individual studies are as follows:
I++: High-quality meta-analyses, systematic reviews
of randomized controlled trials (RCTs), or RCTs with
a very low risk of bias
I+: Well-conducted meta-analyses, systematic
reviews of RCTs, or RCTs with a low risk of bias
I: Meta-analyses, systematic reviews of RCTs, or
RCTs with a high risk of bias
II++: High-quality systematic reviews of case-control
or cohort studies; high-quality case-control or
cohort studies with a very low risk of confounding
or bias and a high probability that the relationship is
causal
II+: Well-conducted case-control or cohort studies
with a low risk of confounding or bias and a
moderate probability that the relationship is causal
II: Case-control or cohort studies with a high risk of
confounding or bias and a significant risk that the
relationship is not causal
III: Nonanalytic studies (e.g., case reports, case
series)
Recommendations for care are formed based on the
body of the evidence. The body of evidence quality
ratings are defined by Grading of Recommendations
Assessment, Development and Evaluation (GRADE)
as follows:
Good quality (GQ): Further research is very unlikely
to change our confidence in the estimate of effect
Moderate quality (MQ): Further research is likely to
have an important impact on our confidence in the
estimate of effect and may change the estimate
Insufficient quality (IQ): Further research is
very likely to have an important impact on our
confidence in the estimate of effect and is likely to
change the estimate; any estimate of effect is very
uncertain
October 2016
aao.org
SUMMARY BENCHMARKS FOR

PREFERRED PRACTICE PATTERN GUIDELINES
Introduction (continued)
Key recommendations for care are defined by GRADE
as follows:
Strong recommendation (SR): Used when the
desirable effects of an intervention clearly outweigh
the undesirable effects or clearly do not
Discretionary recommendation (DR): Used when the
trade-offs are less certaineither because of lowquality evidence or because evidence suggests
that desirable and undesirable effects are closely
balanced
In PPPs prior to 2011, the panel rated recommendations
according to its importance to the care process. This
importance to the care process rating represents
care that the panel thought would improve the quality
of the patients care in a meaningful way. The ratings
of importance are divided into three levels.
Level A, defined as most important
Level B, defined as moderately important
Level C, defined as relevant but not critical
The panel also rated each recommendation on the
strength of evidence in the available literature to
support the recommendation made. The ratings of
strength of evidence also are divided into three levels.
Level I includes evidence obtained from at least

one properly conducted, well-designed randomized
controlled trial. It could include meta-analyses of
randomized controlled trials.
Level II includes evidence obtained from the following:
W
ell-designed controlled trials without
randomization
W
ell-designed cohort or case-control analytic
studies, preferably from more than one center
M
ultiple-time series with or without the
intervention
Level III includes evidence obtained from one of the
following:
Descriptive studies
Case reports
R
eports of expert committees/organizations (e.g.,
PPP panel consensus with external peer review)
This former approach, however, will eventually be
phased out as the AAO adopted the SIGN and
GRADE rating and grading systems.
The PPPs are intended to serve as guides in patient
care, with greatest emphasis on technical aspects. In
applying this knowledge, it is essential to recognize
that true medical excellence is achieved only when
skills are applied in a such a manner that the patients
needs are the foremost consideration. The AAO
is available to assist members in resolving ethical
dilemmas that arise in the course of practice. (AAO
Code of Ethics)
October 2016
aao.org
GLAUCOMA
Primary Open-Angle Glaucoma (Initial Evaluation)
Initial Exam History (Key elements)

Ocular history
Race/ethnicity
Family history
Systemic history
Review of pertinent records
Current medications
Ocular surgery
Initial Physical Exam (Key elements)
Visual acuity measurement
Pupil examination
Slit-lamp biomicroscopy of anterior segment
Measurement of IOP
Central corneal thickness
Gonioscopy
Evaluation of optic nerve head and retinal nerve fiber
layer using magnified stereoscopic visualization with
slit-lamp biomicroscope and through a dilated pupil
(I+, MQ, SR)
Examination of optic nerve head appearance by

color stereophotography or computer-based image
analysis should be serially documented (I+, MQ, SR)
Evaluation of the fundus (through a dilated pupil
whenever feasible)
Visual field evaluation, preferably by automated
static threshold perimetry
Evaluation of the optic disc
Thinning of the inferior and/or superior neuroretinal
rim
Management Plan for Patients in Whom
Therapy is Indicated
Set an initial target pressure of at least 25% lower
than pretreatment IOP. Choosing a lower target IOP
can be justified if there is more severe optic nerve
damage.
Target pressure is an estimate and must be
individualized and/or adjusted during the course of
the disease (III, IQ, DR)
The goal of treatment is to maintain the IOP in
a range at which visual field loss is unlikely to
significantly reduce a patients health-related quality
of life over his/her lifetime (II+, MQ, DR)
Medical therapy is presently the most common initial
intervention to lower IOP; consider balance between
side effects and effectiveness in choosing a regimen
of maximal effectiveness and tolerance to achieve
the desired IOP reduction for each patient
If progression occurs at the target pressure,
undetected IOP fluctuations and adherence to
therapy should be re-evaluated before adjusting
target IOP downward
Assess the patient who is being treated with
glaucoma medication for local ocular and systemic
side effects and toxicity
Laser trabeculoplasty can be considered as initial

therapy in selected patients or an alternative for
patients at high risk for nonadherence to medical
therapy who cannot or will not use medications
reliably due to cost, memory problems, difficulty
with instillation, or intolerance to medication (I+, GQ,
DR)
Trabeculectomy is effective in lowering IOP; it is gen

erally indicated when medications and appropriate
laser therapy are insufficient to control disease and
can be considered in selected cases as initial therapy
(I+, GQ, SR)
Surgery and Postoperative Care for Laser

Trabeculoplasty Patients
The ophthalmologist who performs surgery has the
following responsibilities:
- Obtain informed consent
- Ensure that the preoperative evaluation confirms
the need for surgery
- At least one IOP check within 30 minutes to 2
hours of surgery
- Follow-up examination within 6 weeks of surgery
or sooner if concern about IOP-related optic nerve
damage
Surgery and Postoperative Care for Incisional
Glaucoma Surgery Patients
- Ensure that the preoperative evaluation accurately
documents findings and indications for surgery
- Prescribe topical corticosteroids in the
postoperative period
- Follow-up evaluation on the first postoperative day
(12 to 36 hours after surgery) and at least once
during the first 1 to 2 weeks
- In the absence of complications, perform additional
postoperative visits during a 6-week period
- Schedule more frequent visits, as necessary, for
patients with postoperative complications
- Additional treatments as necessary to maximize
the chances for a successful long-term result
Patient Education for Patients with Medical Therapy
Discuss diagnosis, severity of the disease, prognosis
and management plan, and likelihood of lifelong
therapy
Educate about eyelid closure or nasolacrimal
occlusion when applying topical medications to
reduce systemic absorption
Encourage patients to alert their ophthalmologist
to physical or emotional changes that occur when
taking glaucoma medications
October 2016
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GLAUCOMA
Primary Open-Angle Glaucoma (Follow-up Evaluation)
Exam History
Reassess treatment regimen if target IOP is not

achieved and benefits of a change in therapy
outweigh the risk
Interval ocular history

Interval systemic medical history
Side effects of ocular medications
Frequency and time of last IOP-lowering
medications, and review of medication use
Physical Exam
Slit-lamp biomicroscopy
Measurement of IOP
Evaluation of optic nerve head and visual fields
(see table below)
Measurement of central corneal thickness should
be repeated after any event that may alter it (e.g.,
refractive surgery)
Management Plan For Patients On Medical Therapy
At each exam, record dosage and frequency of use,
discuss adherence to the therapeutic regimen
and patients response to recommendations for
therapeutic alternatives or diagnostic procedures
Perform gonioscopy if there is a suspicion of angle
closure, anterior-chamber shallowing or anteriorchamber angle abnormalities or if there is an
unexplained change in IOP. Perform gonioscopy
periodically.
Adjust target pressure downward if optic disc, retinal

nerve fiber layer, or visual field change is progressive
Within each of the recommended intervals, factors
that determine frequency of evaluation include the
severity of damage, the rate of progression, the
extent to which the IOP exceeds the target pressure
and the number and significance of other risk factors
for damage to the optic nerve
Patient Education
Educate about the disease process, rationale and
goals of intervention, status of their condition, and
relative benefits and risks of alternative interventions
so that patients can participate meaningfully in
developing an appropriate plan of action
Refer for or encourage patients with significant
visual impairment or blindness to use appropriate
vision rehabilitation and social services
Patients considering keratorefractive surgery should
be informed about the possible impact laser vision
correction has on reducing contrast sensitivity and
decreasing the accuracy of IOP measurements
Follow-Up:
Consensus-based Guidelines for Follow-up Glaucoma Status Evaluations with Optic Nerve and Visual Field
Assessment*

Target IOP Achieved
Progression of Damage
Yes
No
Duration of Control
(months)
Approximate Follow-up Interval

(months)**
6 6
Yes
No
6 12
Yes
Yes
NA
No
Yes
NA
12
No
No
NA
36
12
IOP = intraocular pressure; NA = not applicable

**Evaluations consist of clinical examination of the patient, including optic nerve head assessment (with periodic color stereophotography or computerized imaging
of the optic nerve and retinal nerve fiber layer structure) and visual field assessment.
**Patients with more advanced damage or greater lifetime risk from POAG may require more frequent evaluations. These intervals are the maximum recommended
time between evaluations.
October 2016
aao.org
GLAUCOMA
Primary Open-Angle Glaucoma Suspect (Initial and

Follow-up Evaluation)
Follow-up Exam History
Ocular history
Interval ocular history
Family history
Interval systemic medical history and any change of

systemic medications
Systemic history
Review of pertinent records
Current medications
Side effects of ocular medications if patient is being

treated
Ocular surgery
Frequency and time of last glaucoma medications,

and review of use, if patient is being treated
Follow-up Physical Exam

Pupil examination
Slit-lamp biomicroscopy of anterior segment
Measurement of IOP
Central corneal thickness
Gonioscopy
Evaluation of optic nerve head and retinal nerve fiber
layer using magnified stereoscopic visualization with
slit-lamp biomicroscope and through a dilated pupil
Appearance of the optic nerve head and, if possible,
the RNFL should be documented (II++, GQ, SR)
Evaluation of the fundus (through a dilated pupil
whenever feasible)
Visual field evaluation, preferably by automated
static threshold perimetry
Excavation of the optic cup
Thinning of the inferior and/or superior neuroretinal
rim
Therapy is Indicated
A reasonable initial goal is to set a target pressure
20% less than mean of several baseline IOP
measurements based on criteria from the Ocular
Hypertension Study (I+, MQ, DR)
The goal of treatment is to maintain the IOP in
a range at which visual field loss is unlikely to
significantly affect a patients health related quality
of life over his/her lifetime (II+, MQ, DR)
Visual acuity
Measurement of IOP
Gonioscopy is indicated when there is a suspicion
of an angle-closure component, anterior chamber
shallowing or unexplained change in IOP
Follow-up Intervals
Visit intervals depend on the interaction between
patient and disease, which is unique for every patient
Frequency of periodic optic nerve head and visual
field evaluation is based on risk assessment. Patients
with thinner corneas, higher IOPs, disc hemorrhage,
larger cup-to-disc, larger mean pattern standard
deviation, or family history of glaucoma may warrant
closer follow-up.
Patient Education for Patients with Medical Therapy
Discuss diagnosis, number and severity of risk
factors, prognosis, management plan and likelihood
that therapy, once started, will be long term
Educate about disease process, rationale and goals
of intervention, status of their condition, and relative
benefits and risks of alternative interventions
Educate about eyelid closure and nasolacrimal
occlusion when applying topical medications to
reduce systemic absorption
Encourage patients to alert their ophthalmologist
to physical or emotional changes that occur when
taking glaucoma medications
If visual field glaucomatous damage is newly

detected in a glaucoma suspect patient, it is best to
repeat testing (II++, GQ, SR)
Clinicians should include all perimetric and other
structural information in addition to digital imaging
technology when formulating patient management
decisions (III, IQ, SR)
October 2016
aao.org
GLAUCOMA
Primary Angle Closure (Initial Evaluation and Therapy)

Ocular history (symptoms suggestive of intermittent
angle-closure attacks)
Family history of acute angle-closure glaucoma
Systemic history (e.g., use of topical or systemic
medications)
Refractive status
Pupil
- Conjunctival hyperemia (in acute cases)
- Central and peripheral anterior chamber depth
narrowing
- Anterior chamber inflammation suggestive of a
recent or current attack
- Corneal swelling. (Microcystic edema and stromal
edema are common in acute cases.)
- Iris abnormalities, including diffuse or focal
atrophy, posterior synechiae, abnormal pupillary
function, irregular pupil shape, and a mid-dilated
pupil (suggestive of a recent or current attack)
- Lens changes, including cataract and
glaukomflecken
- Corneal endothelial cell loss
Measurement of IOP
Gonioscopy and/or anterior segment imaging of
both eyes
Evaluation of fundus and optic nerve head using
direct ophthalmoscope or slit-lamp biomicroscope
with an indirect lens
Iridotomy is Indicated
Iridotomy is indicated for eyes with PAC or primary
angle-closure glaucoma (I++, GQ, SR)
Laser iridotomy is the preferred surgical treatment
for acute angle-closure crisis (AACC) because it has
a favorable risk-benefit ratio (II+, MQ, SR)
In AACC, use medical therapy first to lower the IOP
to reduce pain and clear corneal edema. Iridotomy
should then be performed as soon as possible. (III,
GQ, SR)
Perform prophylactic iridotomy in fellow eye if

chamber angle is anatomically narrow, as nearly half
of fellow eyes can develop AACC within 5 years (II++,
Surgery and Postoperative Care for Iridotomy

Patients
- Ensure that preoperative evaluation confirms the
need for surgery
- Perform at least one IOP check immediately prior
to surgery and within 30 minutes to 2 hours
following surgery
- Prescribe topical corticosteroids in the
postoperative period
- Ensure that the patient receives adequate
postoperative care
Follow-up evaluations include:
- Evaluation of patency of iridotomy by visualizing
the anterior lens capsule
- Measurement of IOP
- Gonioscopy with compression/indentation, if not
performed immediately after iridotomy
- Pupil dilation to reduce risk of posterior synechiae
formation
- Fundus examination as clinically indicated
Prescribe medications perioperatively to avert
sudden IOP elevation, particularly in patients with
severe disease
Follow-up of Patients with Iridotomy
After iridotomy, follow patients with glaucomatous
optic neuropathy as specified in the Primary OpenAngle Glaucoma PPP
After iridotomy, patients with a residual open angle
or a combination of open angle and some PAS with
or without glaucomatous optic neuropathy should
be followed at least annually, with special attention
to repeat gonioscopy
Education For Patients if Iridotomy is Not Performed
Patients with primary angle-closure suspect who
have not had an iridotomy should be warned
that they are at risk for AACC and that certain
medications cause pupil dilation and include AACC
(III, MQ, DR)
Patients should be informed about the symptoms of

AACC and instructed to notify their ophthalmologist
immediately if symptoms occur (III, MQ, SR)
GQ, SR)
October 2016
aao.org
RETINA
Age-Related Macular Degeneration (Initial and

Follow-up Evaluation)
Symptoms (metamorphopsia, decreased vision,
scotoma, photopsia, difficulties in dark adaptation)
(II, GQ, SR)
Medications and nutritional supplements (II+, GQ, SR)

Ocular history (II+, GQ, SR)
Systemic history (any hypersensitivity reactions)
Family history, especially family history of AMD
(II+, GQ, SR)
Social history, especially smoking (III, GQ, SR)

Comprehensive eye examination (II++, GQ, SR)
Stereo biomicroscopic examination of the macula
(III, GQ, SR)
Diagnostic Tests
Optical coherence tomography is important in
diagnosing and managing AMD, particularly with
respect to determining the presence of subretinal fluid
and in documenting the degree of retinal thickening.
(III, GQ, SR) Optical coherence tomography defines
the cross sectional architecture of the retina in a
manner that is not possible with any other imaging
technology. It may reveal the presence of fluid that is
not apparent on biomicroscopy alone. It also assists
in evaluating the response of the retina and RPE to
therapy by allowing structural changes to be followed
accurately. (II+, GQ, SR)
Intravenous fundus fluorescein angiography in the
clinical setting of AMD is indicated:
when patient complains of new metamorphopsia
when patient has unexplained blurred vision
when clinical exam reveals elevation of the RPE
or retina, subretinal blood, hard exudates or
subretinal fibrosis (II, GQ, SR)
to detect the presence of and determine the extent,
type, size, and location of CNV and to calculate the
percentage of the lesion composed of or consisting
of classic CNV (III, IQ, DR)
to guide treatment (laser photocoagulation surgery
or verteporfin PDT) (III, IQ, DR)
to detect persistent or recurrent CNV following
treatment (III, IQ, DR)
to assist in determining the cause of visual loss that
is not explained by clinical exam (III, IQ, DR)
Each angiographic facility must have a care plan or an
emergency plan and a protocol to minimize the risk
and manage any complications. (III, GQ, SR)
Follow-up Exam History
Visual symptoms, including decreased vision and
metamorphopsia (II, GQ, SR)
Changes in medications and nutritional supplements

(III, GQ, SR)
Changes in ocular history and systemic history

(II+, GQ, SR)
Changes in social history, especially smoking (III, GQ, SR)

Visual acuity (III, GQ, SR)
Stereo biomicroscopic examination of the fundus
(III, GQ, SR)
Follow-up after Treatment for Neovascular AMD

Examine patients treated with intravitreal injections
of aflibercept, bevacizumab, or ranibizumab
approximately 4 weeks after treatment (III, GQ, SR)
Examine and perform fluorescein angiography at least
every 3 months until stable after verteporfin PDT
Examine patients treated with thermal laser
photocoagulation via fluorescein angiography
approximately 2 to 4 weeks after treatment and
then at 4 to 6 weeks (III, GQ, SR)
Subsequent examinations, OCT, and fluorescein
angiography should be performed as indicated
depending on the clinical findings and the judgment
of the treating ophthalmologist (III, GQ, SR)
Patient Education
Educate patients about the prognosis and potential
value of treatment as appropriate for their visual
and functional status (III, GQ, SR)
Encourage patients with early AMD to assess their
own visual acuity and to have regular dilated eye
exams for early detection of intermediate AMD
Educate patients with a high-risk AMD phenotype
about methods of detecting new symptoms of CNV
and about the need for prompt notification to an
ophthalmologist (III, GQ, SR)
Instruct patients with unilateral disease to monitor
their vision in their fellow eye and to return
periodically even in absence of symptoms, but
promptly after onset of new or significant visual
symptoms (III, GQ, SR)
Instruct patients to report symptoms suggestive
of endophthalmitis, including eye pain or increased
discomfort, worsening eye redness, blurred or
decreased vision, increased sensitivity to light, or
increased number of floaters promptly (III, GQ, SR)
Encourage patients who are currently smoking to
stop because there are observational data that
support a causal relationship between smoking
and AMD and other considerable health benefits of
smoking cessation (I++, GQ, SR)
Refer patients with reduced visual function for
vision rehabilitation (see www.aao.org/smart-sightlow-vision) and social services (III, GQ, SR)
October 2016
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RETINA
Age-Related Macular Degeneration (Management

Recommendations)
Treatment Recommendations and Follow-up Plans for Age-Related Macular Degeneration
Recommended Treatment
Diagnoses Eligible for Treatment
Follow-up Recommendations
Observation with no medical or

surgical therapies
No clinical signs of AMD (AREDS category

1)
As recommended in the Comprehensive Adult Medical Eye

Evaluation PPP
Early AMD (AREDS category 2)
Return exam at 6 to 24 months if asymptomatic or prompt

exam for new symptoms suggestive of CNV
OCT, fluorescein angiography, or fundus photos as
appropriate
Advanced AMD with bilateral subfoveal

geographic atrophy or disciform scars

Fundus photos or fluorescein angiography as appropriate
Antioxidant vitamin and mineral

supplements as recommended in
the original AREDS and AREDS2
reports
Intermediate AMD (AREDS category 3)
Monitoring of monocular near vision (reading/Amsler grid)
Advanced AMD in one eye (AREDS

category 4)

Aflibercept intravitreal injection

2.0 mg as described in published
reports
Macular CNV
Fundus photography and/or fundus autofluorescence as

appropriate
Fluorescein angiography and/or OCT for suspicion of CNV
Patients should be instructed to report promptly
symptoms suggestive of endophthalmitis, including eye
pain or increased discomfort, worsening eye redness,
blurred or decreased vision, increased sensitivity to light,
or increased number of floaters
Return examination approximately 4 weeks after treatment
initially; subsequent follow-up and treatment depends
on the clinical findings and judgment of the treating
ophthalmologist. An every 8-week maintenance treatment
regimen has been shown to have comparable results to
every 4 weeks in the first year of therapy.
Bevacizumab intravitreal injection

1.25 mg as described in published
reports
Macular CNV
The ophthalmologist should

provide appropriate informed
consent with respect to the offlabel status
Patients should be instructed to report any symptoms

suggestive of endophthalmitis promptly, including eye pain
or increased discomfort, worsening eye redness, blurred or
decreased vision, increased sensitivity to light, or increased
number of floaters
Return exam approximately 4 weeks after treatment;
subsequent follow-up depends on the clinical findings and
judgment of the treating ophthalmologist
Ranibizumab intravitreal injection

0.5 mg as recommended in
ranibizumab literature
Macular CNV
Patients should be instructed to report any symptoms

suggestive of endophthalmitis promptly, including eye pain
or increased discomfort, worsening eye redness, blurred or
decreased vision, increased sensitivity to light, or increased
number of floaters
Return exam approximately 4 weeks after treatment;
subsequent follow-up depends on the clinical findings and
judgment of the treating ophthalmologist
PDT with verteporfin as

recommended in the TAP and
VIP reports
Macular CNV, new or recurrent, where the

classic component is >50% of the lesion
and the entire lesion is 5400 microns in
greatest linear diameter
Return exam approximately every 3 months until stable,

with retreatments as indicated
Occult CNV may be considered for PDT

with vision <20/50 or if the CNV is <4 MPS
disc areas in size when the vision is >20/50
Juxtafoveal CNV is an off-label indication
for PDT, but may be considered in select
cases.
Thermal laser photocoagulation
surgery as recommended in the
MPS reports
May be considered for extrafoveal classic

CNV, new or recurrent
May be considered for juxtapapillary CNV
Return exam with fluorescein angiography approximately

2 to 4 weeks after treatment, and then at 4 to 6 weeks
and thereafter depending on the clinical and angiographic
findings
Retreatments as indicated
AMD = age-related macular degeneration; AREDS = Age-Related Eye Disease Study; CNV = choroidal neovascularization; MPS = Macular Photocoagulation Study;
OCT = optical coherence tomography; PDT = photodynamic therapy; TAP = Treatment of Age-Related Macular Degeneration with Photodynamic Therapy;
VIP = Verteporfin in Photodynamic Therapy
October 2016
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RETINA
Diabetic Retinopathy (Initial and Follow-up Evaluation)
Ancillary Tests
Duration of diabetes (II++, GQ, SR)
Optical coherence tomography can be used to

quantify retinal thickness, monitor macular edema,
identify vitreomacular traction, and detect other
forms of macular disease in patients with diabetic
macular edema. (III, IQ, DR) Decisions to repeat antiVEGF injections, change therapeutic agents (e.g.,
use of intraocular corticosteroids), initiate laser
treatment, or even consider vitrectomy surgery are
often based in part on OCT findings.
Past glycemic control (hemoglobin A1c) (II++, GQ, SR)

Medications (III, GQ, SR)
Medical history (e.g., obesity, renal disease, systemic
hypertension, serum lipid levels, pregnancy) (II++, GQ,
SR)
Ocular history (III, GQ, SR)

Slit-lamp biomicroscopy (III, GQ, SR)
Measurement of IOP
(III, GQ, SR)
Gonioscopy before dilation when indicated (for

neovascularization of the iris or increased IOP) (III,
GQ, SR)
Pupillary assessment for optic nerve dysfunction

Thorough funduscopy including stereoscopic
examination of the posterior pole (III, GQ, SR)
Examination of the peripheral retina and vitreous,
best performed with indirect ophthalmoscopy or
with slit-lamp biomicroscopy (III, GQ, SR)
Diagnosis
Classify both eyes as to category and severity of
diabetic retinopathy and macular edema. (III, GQ, SR)
Each category has an inherent risk for progression
and is dependent on adherence to overall diabetes
control.
Follow-up History
Visual symptoms (II+, GQ, SR)
Glycemic status (hemoglobin A1c)
(III, GQ, SR)

(III, GQ, SR)
Slit-lamp biomicroscopy with iris examination

(III, GQ, SR)
Gonioscopy (preferably before dilation when iris

neovascularization is suspected or if IOP is elevated)
(III, GQ, SR)
Stereoscopic examination of the posterior pole after

dilation of the pupils (III, GQ, SR)
Examination of the peripheral retina and vitreous
when indicated (III, GQ, SR)
Fluorescein angiography is not routinely indicated

as a part of the examination of patients with
diabetes. (III, GQ, SR)
Ultrasonography enables assessment of the status of
the retina in the presence of a vitreous hemorrhage
or other media opacity, and may be helpful to define
the extent and severity of vitreoretinal traction,
especially on the macula of diabetic eyes. (III, GQ, SR)
Patient Education
Discuss results of exam and implications
(II++, GQ, SR)
Inform patients that effective treatment for diabetic

retinopathy depends on timely intervention, despite
good vision and no ocular symptoms
Educate patients about the importance of
maintaining near-normal glucose levels and nearnormal blood pressure and lowering serum lipid
levels (III, GQ, SR)
OCT imaging when appropriate
Fluorescein angiography is used as a guide for laser

treatment of CSME and as a means of evaluating
the cause(s) of unexplained decreased visual acuity.
(III, IQ, DR) Angiography can identify macular capillary
nonperfusion or sources of capillary leakage
resulting in macular edema as possible explanations
for visual loss. (III, IQ, DR)
Encourage patients with diabetes but without diabetic retinopathy to have annual dilated eye exams
Systemic status (pregnancy, blood pressure, serum

cholesterol, renal status) (III, GQ, SR)
Measurement of IOP
Fundus photography may be useful for

documenting the presence of NVE and NVD, the
response to treatment, and the need for additional
treatment at future visits. (III, IQ, DR)
(III, GQ, SR)
Communicate with the attending physician, e.g.,

family physician, internist, or endocrinologist,
regarding eye findings (III, GQ, SR)
Provide patients whose conditions fail to respond
to surgery and for whom further treatment is
unavailable with proper professional support and
offer referral for counseling, rehabilitative, or social
services as appropriate (III, GQ, SR)
Refer patients with functionally limiting
postoperative visual impairment for vision
rehabilitation (see www.aao.org/smart-sightlow-vision) and social services (III, GQ, SR)
October 2016
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RETINA
Diabetic Retinopathy (Management Recommendations)

Management Recommendations for Patients with Diabetes
Severity of Retinopathy

Presence of
Follow-up
Macular
(Months)
Edema
Panretinal
Focal and/or
Photocoagulation Grid Laser*
(Scatter) Laser
Intravitreal AntiVEGF Therapy
Normal or minimal NPDR
No
12
No
No
No
Mild NPDR
No
12
No
No
No
ME 46 No No No
CSME
1*
No
12
No
Sometimes Sometimes
Moderate NPDR
No
ME 36 No No No
CSME
Severe NPDR
No
ME
CSME
Non-high-risk PDR
No
ME

High-risk PDR
CSME
No
1*
4
No
Sometimes
No
No
Sometimes Sometimes
No
No
24 Sometimes No
No
1*
Sometimes Sometimes Sometimes
Sometimes
No
No
24 Sometimes No
1*
No
Sometimes Sometimes Sometimes
Recommended
No
Alternative1,2
ME
Recommended Sometimes
Usually
CSME
1*
Recommended Sometimes
Usually
Anti-VEGF = anti-vascular endothelial growth factor; CSME = clinically significant macular edema; ME = non-clinically significant macular edema; NPDR =
nonproliferative diabetic retinopathy; PDR = proliferative diabetic retinopathy
* Adjunctive treatments that may be considered include intravitreal corticosteroids or anti-VEGF agents (off-label use, except aflibercept and ranibizumab). Data
from the Diabetic Retinopathy Clinical Research Network in 2011 demonstrated that, at two years of follow-up, intravitreal ranibizumab with prompt or deferred
laser resulted in greater visual acuity gain and intravitreal triamcinolone acetonide plus laser also resulted in greater visual gain in pseudophakic eyes compared
with laser alone. Individuals receiving the intravitreal injections of anti-VEGF agents may be re-examined as early as one month following injection.
E
xceptions include hypertension or fluid retention associated with heart failure, renal failure, pregnancy, or any other causes that may aggravate macular edema.
Deferral of photocoagulation for a brief period of medical treatment may be considered in these cases. Also, deferral of CSME treatment is an option when the
center of the macula is not involved, visual acuity is excellent, close follow-up is possible, and the patient understands the risks.
Or at shorter intervals if signs approaching those of severe NPDR appear.
References:
1. W
riting Committee for the Diabetic Retinopathy Clinical Research Network. Panretinal photocoagulation vs intravitreous ranibizumab for proliferative diabetic
retinopathy: a randomized clinical trial. JAMA 2015;314:213746.
2. Olsen TW. Anti-VEGF pharmacotherapy as an alternative to panretinal laser photocoagulation for proliferative diabetic retinopathy. JAMA 2015;314:21356.
October 2016
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10
Idiopathic Epiretinal Membrane and Vitreomacular Traction

(Initial Evaluation and Therapy)
RETINA
Initial Exam (Key elements)
Surgery and Postoperative Care
Ocular history (e.g., posterior vitreous detachment,

uveitis, retinal breaks, retinal vein occlusions,
proliferative diabetic retinopathy, ocular
inflammatory diseases, recent wound healing)
Vitrectomy surgery is often indicated in patients

who are affected with a decrease in visual acuity,
metamorphopsia, and double vision (II, MQ, DR)
Duration of symptoms (e.g., metamorphopsia,

difficulty using both eyes together, and diplopia)
Race/ethnicity
Systemic history
Physical Exam (Key elements)
Visual acuity
Measurement of IOP
Slit-lamp biomicroscopy of the anterior segment
Spectral domain OCT to diagnose macula and
retinal changes (e.g., proliferation of retinal pigment
epithelial cells and/or retinal glial cells) (III, GQ, SR)
Identify presence of extracellular matrix material,
laminocytes, and/or vitreous cells
ERMs and VMTs often occur together (OCT findings
of VMT are similar, but posterior hyaloid remains
partially attached to macula)
Fluorescein angiogram may be helpful in evaluating
ERMs and/or VMTs and associated retinal
pathologies
Management Plan
The decision to intervene surgically in patients with
ERM/VMT usually depends upon the severity of
symptoms, especially the impact on daily activities
Patients should be informed that the majority of
ERMs will remain stable and do not require therapy
(GQ, SR)
Patients should be reassured that there is a very

successful surgical procedure that could address
worsening symptoms or decreasing visual acuity
(GQ, SR)
Patients do not typically improve without

vitrectomy surgery when the area of VMT is broad
(>1500 m), when there is an accompanying
pathologic detachment of the macula, or when the
presenting visual acuity is poor (III, IQ, DR)
Vitrectomy surgery for ERM or VMT usually leads
to an improvement in visual acuity since the outer
retina, ellipsoid zone, and the photoreceptors outer
segment length may improve or even normalize
after surgery (III, IQ, DR)
A patient with an ERM should be informed that it
is unlikely that intravitreal ocriplasmin will lead to
effective treatment (III, GQ, SR)
Hypotony and elevated IOPs are a well-known risk
of vitrectomy surgery and should be monitored
postoperatively
Patients should be examined postoperatively
day 1, and again 1 to 2 weeks following surgery,
or sooner depending upon the development
of new symptoms or new findings during early
postoperative examination (GQ, SR)
Patient Education and Follow-up
Comparing OCT images in the abnormal versus
normal eye can aid patient understanding
Patients should be encouraged to periodically test
their central vision monocularly to detect changes
that may occur over time, like small central scotoma
(GQ, SR)
Patients should be informed to notify their

ophthalmologist promptly if they have symptoms
such as an increase of floaters, loss of visual field,
metamorphopsia, or a decrease in visual acuity (III,
GQ, SR)
Risks versus benefits of vitrectomy surgery should

be discussed. Risks include cataract, retinal tears,
retinal detachment, and endophthalmitis
October 2016
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11
RETINA
Idiopathic Macular Hole (Initial Evaluation and Therapy)
Duration of symptoms
(III, GQ, DR)
Ocular history: glaucoma, retinal detachment or tear,

other prior eye diseases or injuries, ocular surgery,
or prolonged sun or eclipse gazing (III, GQ, DR)
Slit-lamp biomicroscopic examination of the macula

and the vitreoretinal interface, and the optic disc
Medications that may be related to macular cystoid

edema (III, GQ, DR)
Indirect peripheral retinal examination
(III, GQ, SR)

(III, GQ, SR)
Management Recommendations for Macular Hole

Stage Management Follow-up
1-A and 1-B
Observation
Follow-up at 24 month intervals in the absence of new symptoms
Recommend prompt return if new symptoms develop
Encourage monocular visual acuity testing with Amsler grid
Follow-up at 12 days postoperatively, then 12 weeks
Vitreoretinal surgery*
Frequency and timing of subsequent visits varies depending on the

outcome of surgery and the patients clinical course

If no surgery, follow up every 24 months
Vitreopharmacolysis Follow-up at 1 week and 4 weeks, or with new symptoms (i.e., retinal
detachment symptoms)
3 or 4
Vitreoretinal surgery
Follow-up at 12 days postoperatively, then 12 weeks
Frequency and timing of subsequent visits varies depending on the

outcome of surgery and the patients clinical course
* Although surgery is usually performed, observation may also be appropriate in selected cases.
Although ocriplasmin has been approved by the U.S. Food and Drug Administration for vitreomacular adhesion, its use for treatment of idiopathic macular hole
without vitreomacular traction or adhesion would currently be considered off-label use.
Surgical and Postoperative Care if Patient Receives

Treatment
Inform the patient about relative risks, benefits,
and alternatives to surgery, and the need for use
of expansile intraocular gas or facedown positioning
postoperatively (III, GQ, SR)
Formulate a postoperative care plan and inform the
patient of these arrangements (III, GQ, SR)
Inform patients with glaucoma of possible
postoperative increase in IOP (III, GQ, SR)
Examine postoperatively within 1 or 2 days and
again 1 to 2 weeks after surgery (III, GQ, DR)
Patient Education
Inform patients to notify their ophthalmologist
promptly if they have symptoms such as an increase
in floaters, a loss of visual field, metamorphopsia, or
a decrease in visual acuity (III, GQ, SR)
Inform patients that air travel, travel to high
altitudes, or general anesthesia with nitrous oxide
should be avoided until the gas tamponade is nearly
completely gone (III, GQ, SR)
Inform patients who have had a macular hole in one
eye that they have a 10% to 15% chance of macular
hole formation in the fellow eye, especially if the
vitreous remains attached (III, GQ, SR)
Refer patients with functionally limiting
postoperative visual impairment for vision
rehabilitation (see www.aao.org/smart-sightlow-vision) and social services (III, GQ, SR)
October 2016
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12
Posterior Vitreous Detachment, Retinal Breaks, and Lattice

Degeneration (Initial and Follow-up Evaluation)
Symptoms of PVD (II+, GQ, SR)
Family history of RD, related genetic disorders
(II, GQ, SR)
Prior eye trauma (III, GQ, SR)

Myopia (II+, GQ, SR)
History of ocular surgery including refractive lens
exchange and cataract surgery (II++, GQ, SR)
Confrontation visual field examination, and assessing
for the presence of a relative afferent pupillary
defect (III, GQ, SR)
Examination of the vitreous for hemorrhage,
detachment, and pigmented cells (II+, GQ, SR)
Examination of the peripheral fundus with scleral
depression. The preferred method of evaluating
peripheral vitreoretinal pathology is with indirect
ophthalmoscopy combined with scleral depression.
(III, GQ, SR)
Ancillary Tests
Optical coherence tomography may be helpful to
evaluate and stage the PVD (II+, MQ, DR)
Perform B-scan ultrasonography if peripheral retina
cannot be evaluated. If no abnormalities are found,
frequent follow-up examinations are recommended.
(III, IQ, DR)
Surgical and Postoperative Care if Patient

Receives Treatment:
Inform patient about the relative risks, benefits, and
alternatives to surgery (III, GQ, SR)
RETINA
Formulate a postoperative care plan and inform

patient of these arrangements (III, GQ, SR)
Advise patient to contact ophthalmologist
promptly if they have a substantial change in
symptoms such as floaters, visual field loss, or
decreased visual acuity (II+, GQ, SR)
Follow-up History
Visual symptoms (III, GQ, SR)
Interval history of eye trauma or intraocular surgery
(III, GQ, SR)

Evaluation of the status of the vitreous, with
attention to the presence of pigment, hemorrhage,
or syneresis (III, GQ, SR)
Examination of the peripheral fundus with scleral
depression (III, GQ, SR)
Optical coherence tomography if vitreomacular
traction is present (III, GQ, SR)
B-scan ultrasonography if the media are opaque
(III, GQ, SR)
Patient Education
Educate patients at high risk of developing retinal
detachment about the symptoms of PVD and retinal
detachment and the value of periodic follow-up
exams (III, GQ, SR)
Instruct all patients at increased risk of retinal
detachment to notify their ophthalmologist
promptly if they have a substantial change in
symptoms such as increase in floaters, loss of visual
field, or decrease in visual acuity (II+, GQ, SR)
Care Management
Management Options
Type of Lesion
Treatment*
Acute symptomatic horseshoe tears
Treat promptly
Acute symptomatic operculated tears
Treatment may not be necessary
Acute symptomatic dialyses
Treat promptly
Traumatic retinal breaks
Usually treated
Asymptomatic horseshoe tears (without subclinical RD)
Often can be followed without treatment
Asymptomatic operculated tears
Treatment is rarely recommended
Asymptomatic atrophic round holes
Treatment is rarely recommended
Asymptomatic lattice degeneration without holes
Not treated unless PVD causes a horseshoe tear
Asymptomatic lattice degeneration with holes
Usually does not require treatment
Asymptomatic dialyses No consensus on treatment and insufficient evidence to guide

management
Eyes with atrophic holes, lattice degeneration, or
asymptomatic horseshoe tears where the fellow eye
has had a RD
No consensus on treatment and insufficient evidence to guide

management
PVD = posterior vitreous detachment; RD = retinal detachment

*There is insufficient evidence to recommend prophylaxis of asymptomatic retinal breaks for patients undergoing cataract surgery.
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13
Retinal and Ophthalmic Artery Occlusions (Initial Evaluation

and Therapy)
Initial exam should include all aspects of a
comprehensive adult medical eye evaluation (see
Comprehensive Adult Medical Eye Evaluation PPP
for details) with special attention paid to retinal
vascular disease elements (II+, MQ, SR)
Medical history should include a careful review of
systems for embolic disease (e.g., transient ischemic
symptoms, lateralizing weakness, paresthesias)
GCA symptoms (e.g., headaches, scalp tenderness,
malaise, fatigue, temporal tenderness, fever, history
of polymyalgia rheumatic) must be recognized
Visual acuity
Measurement of IOP
Dilated examination of the far peripheral retina with
indirect ophthalmoscopy
RETINA
opacity
Care Management
Acute symptomatic OAO, CRAO, or BRAO represent
urgent ophthalmic conditions and require prompt
evaluation
Physicians should immediately consider GCA in
patients 50 years of age or older
In cases of GCA, physicians should initiate urgent
systemic corticosteroid therapy to prevent
vision loss in the fellow eye or vascular occlusion
elsewhere (I-/I+, GQ, SR)
Diabetics should be carefully monitored since
systemic corticosteroid treatment may destabilize
glucose control
Ophthalmologists should refer patients with retinal
vascular disease to the appropriate setting, depending
on the nature of the retinal occlusion.
Gonioscopy when IOP is elevated or when iris

neovascularization risk is suspected (prior to
dilation)
Acute symptomatic OAOs or CRAOs from embolic

etiologies should prompt an immediate referral to
the nearest stroke center
Funduscopy
At present there is no evidence in support of

treating asymptomatic patients who have a BRAO
with an expedited stroke work-up
Relative afferent pupil defect assessment

Slit-lamp biomicroscopy of the posterior pole
Examination of the peripheral retina using indirect
ophthalmoscopy through a dilated pupil to assess:
retinal hemorrhages, cotton-wool spots, retinal
emboli, retinal vascular boxcarring, and optic disc
neovascularization
Diagnostic Tests
Color and red-free fundus photography
Patient Follow-up
Follow-up should consider the extent of retinal or
ocular ischemia neovascularization. Patients with
greater ischemia require more frequent follow-up
Many patients with retinal vascular disease will lose
substantial vision despite various treatment options
and should be referred for appropriate social
services and vision rehabilitation
Fluorescein angiogram
Optical coherence tomography
Ultrasonography in the setting of significant media
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14
RETINA
Retinal Vein Occlusions (Initial Evaluation and Therapy)

Ocular history (e.g., glaucoma, other ophthalmologic
disorders, ocular injections, surgery, including retinal
laser treatment, cataract surgery, refractive surgery)
Location and duration of vision loss
Current medications
Systemic history (e.g., systemic hypertension,
diabetes, hyperlipidemia, cardiovascular disease,
sleep apnea, coagulopathies, thrombotic disorders,
and pulmonary embolus)
Visual acuity
Measurement of IOP
Slit-lamp biomicroscopy to detect fine abnormal
new iris vessels
Dilated examination of the far peripheral retina with
indirect ophthalmoscopy
Gonioscopy prior to pupil dilation; especially in
cases of an ischemic CRVO, when IOP is elevated, or
when iris neovascularization risk is high
Binocular funduscopic evaluation of the posterior
pole
Diagnostic Tests
Color fundus photography to document retinal
findings
Multiple studies have demonstrated the efficacy

of anti-VEGF agents in the treatment of macular
edema associated with BRVO (I++, GQ, SR)
Randomized controlled studies have shown the
efficacy of anti-VEGF agents in treating macular
edema related to CRVO (I++, GQ, SR)
Betadine antiseptic drops and a lid speculum are
recommended during all intravitreal injections (III, MQ,
DR)
Intravitreal triamcinolone, dexamethasone, and other

corticosteroids have been shown to be efficacious
for macular edema associated with CRVO, yet
there are known associated risks of cataracts and
glaucoma (I+, GQ, SR)
Laser treatment remains a viable treatment in eyes
with BRVO, even if the duration of the disease is
greater than 12 months (I+, GQ, SR)
Sectoral pan retinal photocoagulation is still
recommended for neovascularization when
complications such as vitreous hemorrhage or iris
neovascularization occur (I+, GQ, SR)
Ophthalmologists caring for patients with retinal
vascular occlusion should be familiar with specific
recommendations of relevant clinical trials due to
the complexity of diagnosis and treatment (I++, GQ,
SR)
Patient Follow-up
Optical coherence tomography to detect macular

disease
Ophthalmologist should refer patients with an RVO

to a primary care physician for appropriate
management of their systemic condition and
communicate results to the physician managing the
patients ongoing care (I+, GQ, SR)
Ultrasonography (e.g., when vitreous hemorrhage is

present)
Risk to the fellow eye should be communicated to

both the primary care provider and the patient (I+,
Fluorescein angiogram to evaluate the degree of

vascular occlusion
Care Management
Best prevention is to manage risk factors
aggressively by optimizing control of diabetes
mellitus, hypertension, and hyperlipidemia (I+, GQ, SR)
Participants who received a 4-mg corticosteroid
treatment dose had higher rates of cataract
formation, cataract surgery, and elevated IOP,
indicating a preference for a 1-mg dose (I++, GQ, SR)
MQ, SR)
Patients whose conditions fail to respond to therapy

and when further treatment is unavailable should be
provided with professional support and offered a
referral for counseling, vision rehabilitation, or social
services as appropriate (I++, GQ, SR)
October 2016
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15
CATARACT
Cataract (Initial and Follow-up Evaluation)
Preoperative Care
Symptoms
The ophthalmologist who is to perform the surgery

has the following responsibilities:
Ocular history
Systemic history
Assessment of visual function status
Medications currently used
Visual acuity with current correction
Measurement of BCVA (with refraction when
indicated)
External examination
Ocular alignment and motility
Glare testing when indicated
Pupil reactivity and function
Measurement of IOP
Slit-lamp biomicroscopy, including gonioscopy
Dilated examination of the lens, macula, peripheral
retina, optic nerve, and vitreous through a dilated pupil
Assessment of relevant aspects of the patients
medical and physical status
Care Management
Treatment is indicated when visual function no
longer meets the patients needs and cataract
surgery provides a reasonable likelihood of qualityof-life improvement
Cataract removal is also indicated when there is
evidence of lens-induced disease or when it is
necessary to visualize the fundus in an eye that has
the potential for sight
Surgery should not be performed under the
following circumstances:
- Tolerable refractive correction provides vision that
meets the patients needs and desires; surgery is
not expected to improve visual function, and no
other indication for lens removal exists
- The patient cannot safely undergo surgery
because of coexisting medical or ocular conditions
- Appropriate postoperative care cannot be
arranged
- Patient or patients surrogate decision maker is
unable to give informed consent for nonemergent
surgery
Examine the patient preoperatively

Ensure that the evaluation accurately documents
symptoms, findings, and indications for treatment
Inform the patient about the risks, benefits,
and expected outcomes of surgery, including
the anticipated refractive outcome or surgical
experience
Formulate surgical plan, including selection of IOL
and anesthesia
Review results of presurgical and diagnostic
evaluations with the patient
Inform the patient about the possibility of visual
impairment continuing after cataract surgery, and
the potential for rehabilitation (III, GQ, SR)
Formulate postoperative plans and inform patient of
arrangements
Answer patients questions regarding surgery, care,
and cost
Routine preoperative laboratory testing in
association with the history and physical
examination is not indicated (I+, GQ, SR)
Follow-up Evaluation
High-risk patients should be seen within 24 hours of
surgery
Routine patients should be seen within 48 hours of
surgery
Frequency and timing of subsequent visits depend
on refraction, visual function, and medical condition
of the eye
More frequent follow-up usually necessary for high
risk patients
Components of each postoperative exam should
include:
- Interval history, including new symptoms and use
of postoperative medications
- Patients assessment of visual function status
- Measurement of IOP
- Slit-lamp biomicroscopy
- Operating ophthalmologist should provide
postoperative care that is within the unique
competence of the ophthalmologist (III, GQ, SR)
Indications for second eye surgery are the same as

for the first eye (with considerations given to needs
for binocular function)
The standard of care in the United States is a smallincision phacoemulsification with foldable IOL
implantation with either biaxial or coaxial approach
(I+, GQ, SR)
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CATARACT
Cataract (Initial and Follow-up Evaluation) (continued)
Nd:YAG Laser Capsulotomy

Treatment is indicated when vision impaired by
posterior capsular opacification does not meet
the patients functional needs or when it critically
interferes with visualization of the fundus
Educate about the symptoms of posterior vitreous
detachment, retinal tears, and detachment and the
need for immediate examination if these symptoms
are noticed
The decision to perform capsulotomy should take
into account the benefits and risks of the laser
surgery. Laser posterior capsulotomy should not be
performed prophylactically (i.e., when the capsule
remains clear). The should be inflammatory-free
and the IOL stable prior to performing Nd:YAG laser
capsulotomy. (III, GQ, SR)
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CORNEA
Bacterial Keratitis (Initial Evaluation)
Initial Exam History
Indications for smears and cultures:
Ocular symptoms (e.g., degree of pain, redness,

discharge, blurred vision, photophobia, duration of
symptoms, circumstances surrounding the onset of
symptoms) (III, GQ, SR)
- Sight-threatening or severe keratitis of suspected

micro bial origin prior to initiating therapy. (III, IQ,
Contact lens history (e.g., wearing schedule,

overnight wear, type of contact lenses, contact lens
solution, contact lens hygiene protocol, tap-water
rinse of contact lenses, swimming, using a hot tub,
or showering while wearing contact lenses) (II+, GQ,
SR)
Review of other ocular history, including risk factors

such as herpes simplex virus keratitis, varicella
zoster virus keratitis, previous bacterial keratitis,
trauma, dry eye, and previous ocular surgery,
including refractive surgery (III, GQ, SR)
Review of other medical problems
(III, GQ, SR)
Current and recently used ocular medications (III, GQ,

SR)
Medication allergies (III, GQ, SR)

Initial Physical Exam
DR)
- A large central corneal infiltrate that extends to

the middle to deep stroma. (III, IQ, DR)
- Chronic in nature.
(III, IQ, DR)
- Unresponsive to broad spectrum antibiotic

therapy. (III, IQ, DR)
- Clinical features suggestive of fungal, ambic, or
mycobacterial keratitis. (III, IQ, DR)
The hypopyon that occurs in eyes with bacterial
keratitis is usually sterile, and aqueous or vitreous
taps should not be performed unless there is a high
suspicion of microbial endophthalmitis. (III, IQ, DR)
Corneal scrapings for culture should be inoculated
directly onto appropriate culture media to maximize
culture yield. (III, IQ, DR) If this is not feasible, place
specimens in transport media. (II+, MQ, DR) In
either case, immediately incubate cultures or take
promptly to the laboratory. (III, GQ, SR)
Care Management
General appearance of patient, including skin

conditions (III, GQ, SR)
Topical antibiotic eye drops are preferred method in

most cases. (III, GQ, SR)
Facial examination (III, GQ, SR)
Use topical broad-spectrum antibiotics initially in

the empiric treatment of presumed bacterial
keratitis. (III, IQ, DR)
Globe position (III, GQ, SR)

Eyelids and eyelid closure
(III, GQ, SR)
Conjunctiva (III, GQ, SR)

Nasolacrimal apparatus (III, GQ, SR)
Corneal sensation (III, GQ, SR)
Slit-lamp biomicroscopy (III, GQ, SR)
- Eyelid margins
- Conjunctiva
- Sclera
(III, GQ, SR)
(III, GQ, SR)
(III, GQ, SR)
- Cornea
(III, GQ, SR)
- Anterior chamber for depth and the presence of

inflammation, including cell and flare, hypopyon,
fibrin, hyphema (III, GQ, SR)
- Anterior vitreous (III, GQ, SR)
- Contralateral eye for clues to etiology as well as
possible similar underlying pathology (III, GQ, SR)
Diagnostic Tests
Manage majority of community-acquired cases
with empiric therapy and without smears or
cultures. (III, IQ, DR)
For central or severe keratitis (e.g., deep stromal

involvement or an infiltrate larger than 2 mm with
extensive suppuration), use a loading dose (e.g.,
every 5to 15 minutes for the first 30 to 60 minutes),
followed by frequent applications (e.g., every 30
minutes to 1hour around the clock). (III, IQ, DR) For
less severe keratitis, a regimen with less frequent
dosing is a
ppropriate. (III, IQ, DR)
Use systemic therapy for gonococcal keratitis. (III, IQ,
DR)
For patients treated with ocular topical

corticosteroids at time of presentation of suspected
bacterial keratitis, reduce or eliminate corticosteroids
until infection has been controlled. (III, GQ, SR)
When the corneal infiltrate compromises the
visual axis, may add topical corticosteroid therapy
following at least 2 to 3 days of progressive
improvement with treatment with topical antibiotics.
(III, IQ, DR) Continue topical antibiotics at high levels
with gradual tapering. (III, IQ, DR)
Examine patients within 1 to 2 days after initiation of
topical corticosteroid therapy. (III, IQ, DR)
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CORNEA
Bacterial Keratitis (Management Recommendations)
Patient Education
Inform patients with risk factors predisposing them
to bacterial keratitis of their relative risk, the signs
and symptoms of infection, and to consult an
ophthalmologist promptly if they experience such
warning signs or symptoms (III, GQ, SR)
Educate about the destructive nature of bacterial
keratitis and need for strict compliance with therapy
(III, GQ, SR)
E
ducate patients with contact lenses about
increased risk of infection associated with contact
lens, overnight wear, and importance of adherence
to techniques to promote contact lens hygiene (II+,
GQ, SR)
R
efer patients with significant visual impairment
or blindness for vision rehabilitation if they are not
surgical candidates (see www.aao.org/smart-sightlow-vision)
Discuss possibility of permanent visual loss and need

for future visual rehabilitation (III, GQ, SR)
Antibiotic Therapy of Bacterial Keratitis

Topical Subconjunctival
Organism
Antibiotic
Concentration Dose
No organism
identified or
multiple types
of organisms

Cefazolin
50 mg/ml
with
Tobramycin or gentamicin
914 mg/ml
or
Fluoroquinolones* Various
100 mg in 0.5 ml
Gram-positive
Cocci

Cefazolin
50 mg/ml
Vancomycin
1550 mg/ml
Bacitracin
10,000 IU
Fluoroquinolones* Various
100 mg in 0.5 ml
25 mg in 0.5 ml
Gram-negative
Rods

Tobramycin or gentamicin
914 mg/ml
Ceftazidime
50 mg/ml
Fluoroquinolones Various
20 mg in 0.5 ml
100 mg in 0.5 ml
Gram-negative
Cocci

Ceftriaxone
50 mg/ml
Ceftazidime
50 mg/ml
100 mg in 0.5 ml
100 mg in 0.5 ml
Nontuberculous
Amikacin
2040 mg/ml
Mycobacteria
Clarithromycin
10 mg/ml
Azithromycin||
10 mg/ml

Nocardia
Sulfacetamide

Amikacin
Trimethoprim/
Sulfamethoxazole:

Trimethoprim

Sulfamethoxazole
100 mg/ml
2040 mg/ml
20 mg in 0.5 ml
20 mg in 0.5 ml
20 mg in 0.5 ml
16 mg/ml
80mg/ml
* Fewer gram-positive cocci are resistant to gatifloxacin and moxifloxacin than other fluoroquinolones.
B
esifloxacin 6mg/ml; ciprofloxacin 3 mg/ml; gatifloxacin 3 mg/ml; levofloxacin 15 mg/ml; moxifloxacin 5 mg/ml; ofloxacin 3 mg/ml, all commercially available at
these concentrations
For resistant Enterococcus and Staphylococcus species and penicillin allergy. Vancomycin and bacitracin have no gram-negative activity and should not be used as
a single agent in empirically treating bacterial keratitis.
Systemic therapy is necessary for suspected gonococcal infection.
|| Data from Chandra NS, Torres MF, Winthrop KL. Cluster of Mycobacterium chelonae keratitis cases following laser in-situ keratomileusis. Am J Ophthalmol 2001;
132:81930.
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CORNEA
Blepharitis (Initial and Follow-up Evaluation)
Diagnostic Tests
Ocular symptoms and signs (e.g., redness, irritation,

burning, tearing, itching, crusting of eyelashes, eyelid
sticking, contact lens intolerance, photophobia,
increased frequency of blinking) (III, GQ, SR)
Cultures may be indicated for patients with

recurrent anterior blepharitis with severe
inflammation as well as for patients who are not
responding to therapy. (III, IQ, DR)
Time of day when symptoms are worse

Duration of symptoms
Unilateral or bilateral presentation
Exacerbating conditions (e.g., smoke, allergens,
wind, contact lenses, low humidity, retinoids, diet
and alcohol consumption, eye makeup)
Symptoms related to systemic diseases (e.g.,
rosacea, allergy) (III, IQ, DR)
Current and previous systemic and topical
medications (e.g., antihistamines or drugs with
anticholinergic effects, or drugs used in the past
that might have an effect on the ocular surface [e.g.,
isotretinoin]) (III, GQ, SR)
Recent exposure to an infected individual (e.g.,
pediculosis palpebrarum [Pthirus pubis])
Ocular history (e.g., previous intraocular and eyelid
surgery, local trauma, including mechanical, thermal,
chemical, and radiation injury, history of cosmetic
blepharoplasty, history of styes and/or chalazia)
(III, GQ, SR)

(III, GQ, SR)
- Eyelids (III, GQ, SR)
A topical antibiotic such as bacitracin or

erythromycin can be prescribed to be applied one
or more times daily or at bedtime on the eyelids for
one or more weeks. (III, IQ, DR)
For patients with meibomian gland dysfunction,
whose chronic symptoms and signs are not
adequately controlled with eyelid hygiene, oral
tetracyclines and topical antibiotics can be
prescribed. (I, MQ, DR)
(III, GQ, SR)
(III, GQ, SR)
(III, GQ, SR)
- External examination
(III, GQ, SR)
- Tarsal conjunctiva (everting eyelids)

- Cornea
(III,
IQ, DR)
- Measurement of visual acuity
(III, GQ, SR)
- Bulbar conjunctiva
Treat patients with blepharitis initially with a

regimen of warm compresses and eyelid hygiene.
- Interval history
- Anterior eyelid margin (III, GQ, SR)

- Posterior eyelid margin
Care Management
Follow-up visits should include:
(III, GQ, SR)
- Eyelashes
(III, GQ, SR)
Follow-Up Evaluation
- Tear film
Consult with the pathologist prior to obtaining the

biopsy if sebaceous cell carcinoma is suspected.
A brief course of topical corticosteroids may be

helpful for eyelid or ocular surface inflammation. The
minimal effective dose of corticosteroid should be
utilized and long-term corticosteroid therapy should
be avoided if possible. (III, GQ, SR)

- Skin
Biopsy of the eyelid to exclude the possibility of

carcinoma may be indicated in cases of marked
asymmetry, resistance to therapy or unifocal
recurrent chalazia that do not respond well to
therapy. (III, IQ, DR)
(III, GQ, SR)
(III, GQ, SR)
(III, GQ, SR)
- Slit-lamp biomicroscopy (III, GQ, SR)

If corticosteroid therapy is prescribed, re-evaluate
patient within a few weeks to determine the
response to therapy, measure intraocular pressure,
and assess treatment compliance (III, GQ, SR)
Patient Education
Counsel patients about the chronicity and
recurrence of the disease process. (III, GQ, SR)
Inform patients that symptoms can frequently be
improved but are rarely eliminated. (III, GQ, SR)
Patients with an inflammatory eyelid lesion that
appears suspicious for malignancy should be referred
to an appropriate specialist. (III, GQ, SR)
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CORNEA
Conjunctivitis (Initial Evaluation)
Slit-lamp biomicroscopy (III, IQ, DR)
Ocular symptoms and signs (e.g., itching, discharge,

irritation, pain, photophobia, blurred vision)
- Eyelid margins (inflammation, ulceration,

discharge, nodules or vesicles, blood-tinged
debris, keratinization) (III, IQ, DR)
Duration of symptoms and time course

Exacerbating factors
Character of discharge
Recent exposure to an infected individual
Trauma (mechanical, chemical, ultraviolet)
Mucus fishing
Contact lens wear (lens type, hygiene and use
regimen)
Symptoms and signs potentially related to systemic
diseases (e.g., genitourinary discharge, dysuria,
dysphagia, upper respiratory infection, skin and
mucosal lesions)
Allergy, asthma, eczema
Use of topical and systemic medications
Ocular history (e.g., previous episodes of
conjunctivitis and previous ophthalmic surgery)
Compromised immune status
Current and prior systemic diseases
- Eyelashes (loss of lashes, crusting, scurf, nits, lice,

trichiasis) (III, IQ, DR)
- Lacrimal puncta and canaliculi (pouting,
discharge) (III, IQ, DR)
- Tarsal and forniceal conjunctiva (III, IQ, DR)
- Bulbar conjunctiva/limbus (follicles, edema,
nodules, chemosis, laxity, papillae, ulceration,
scarring, phlyctenules, hemorrhages, foreign
material, keratinization) (III, IQ, DR)
- Cornea (III, IQ, DR)
- Anterior chamber/iris (inflammation reaction,
synechiae, transillumination defects) (III, IQ, DR)
- Dye-staining pattern (conjunctiva and cornea)
(III, IQ, DR)
Diagnostic Tests
Cultures, smears for cytology and special stains are
indicated in cases of suspected infectious neonatal
conjunctivitis. (II, IQ, DR)
Social history (e.g., smoking, occupation and

hobbies, travel and sexual activity)
Smears for cytology and special stains are

recommended in cases of suspected gonococcal
conjunctivitis. (II, IQ, DR)
Confirm diagnosis of adult and neonate chlamydial

conjunctivitis with immunodiagnostic test and/or
culture.
Visual acuity (III, IQ, DR)

External examination (III, IQ, DR)
- Skin (signs of rosacea, eczema, seborrhea) (III, IQ,
DR)
- Abnormalities of the eyelids and adnexae

(swelling, discoloration, malposition, laxity,
ulceration, nodules, ecchymosis, neoplasia) (III, IQ,
DR)
- Conjunctiva (pattern of injection, subconjunctival

hemorrhage, chemosis, cicatricial change,
symblepharon, masses, discharge) (III, IQ, DR)
Biopsy the bulbur conjunctiva and take a sample

from an uninvolved area adjacent to the limbus in an
eye with active inflammation when ocular mucous
membrane pemphigoid is suspected. (II, IQ, DR)
A full-thickness lid biopsy is indicated in cases of
suspected sebaceous carcinoma. (III, IQ, DR)
Confocal microscopy may be helpful to evaluate
some forms of conjunctivitis (e.g., atopic, SLK). (II,
MQ, DR)
Thyroid function tests are indicated for patients with

SLK who do not have known thyroid disease. (III, IQ,
DR)
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CORNEA
Conjunctivitis (Management Recommendations)
Care Management
Avoid indiscriminate use of topical antibiotics or

corticosteroids because antibiotics can induce
toxicity and corticosteroids can potentially prolong
adenoviral infections and worsen herpes simplex
virus infections (III, GQ, SR)
Follow-up visits should include
Treat mild allergic conjunctivitis with an over-thecounter antihistamine/vasoconstrictor agent or

second-generation topical histamine H1-receptor
antagonists. If the condition is frequently recurrent
or persistent, use mast-cell stabilizers (I++, GQ, SR)
If corticosteroids are used, perform periodic

measurement of intraocular pressure and pupillary
dilation to evaluate for cataract and glaucoma (III, IQ,
For contact lens-related keratoconjunctivitis,

discontinue contact lens wear for 2 or more weeks
(III, IQ, DR)
If corticosteroids are indicated, prescribe the lowest

potency and frequency based on patient response
and tolerance (III, IQ, DR)
If corticosteroids are used, perform baseline and
periodic measurement of intraocular pressure and
pupillary dilation (III, IQ, DR)
Use systemic antibiotic treatment for conjunctivitis
due to Neisseria gonorrhoeae or Chlamydia
trachomatis (III, IQ, DR)
- Interval history
(III, IQ, DR)
- Visual acuity (III, IQ, DR)

- Slit-lamp biomicroscopy
(III, IQ, DR)
DR)
Patient Education
Counsel patients with contagious varieties to minimize or prevent spread of diseases in the
community (III, IQ, DR)
Inform patients who may require repeat short-term
therapy with topical corticosteroid of potential
complications of corticosteroid use
Advise patients with allergic conjunctivitis that
frequent clothes washing and bathing/showering
before bedtime may be helpful (III, IQ, DR)
Treat sexual partners to minimize recurrence and

spread of disease when conjunctivitis is associated
with sexually transmitted diseases and refer patients
and their sexual partners to an appropiate medical
specialist (III, GQ, SR)
Refer patients with manifestation of a systemic
disease to an appropriate medical specialist (III, GQ,
SR)
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CORNEA
Corneal Ectasia (Initial and Follow-up Evaluation)

Disease onset and course
Vision impairment
Ocular, medical, and family history
Visual function assessment
- Corneal protrusion
- Eyelids and periorbital skin
- Presence, extent, and location of the corneal
thinning or protrusion
- Indication of previous ocular surgery
- Presence of Vogt striae, prominent corneal nerves,
Fleischer ring, or other iron deposition
- Evidence of corneal scarring or previous hydrops,
and presence of prominent corneal nerves
IOP measurement (III, IQ, DR)
Fundus examination: assessment of red reflex for
dark area, and retina for tapetoretinal degenerations
(III, IQ, DR)
Diagnostic Tests
Keratometry (II+, MQ, DR)
Corneal topography (II, MQ, SR)
Topographic power map
Topographic elevation map (II+, MQ, DR)
Corneal pachymetry (II++, GQ, SR)
Care Management
Therapy is tailored to the individual patient,
depending on the visual impairment and treatment
option(s).
Vision can be corrected with eyeglasses, but contact
lenses may be required as keratoconus progresses.
Rigid corneal gas permeable contact lenses can
mask corneal irregularities. New hybrid contact
lenses provide higher oxygen permeability and
greater RGP/hydrogel junction strength. Piggyback
contact lenses may be employed in cases of corneal
scaring or decentered cones. Scleral lenses may be
indicated when RGP and/or hybrid contact lenses
fail.
Intrastromal corneal ring segment implantation
can improve contact lens tolerance and BCVA for
patients with corneal ectasia, a clear cornea, and
contact lens intolerance. (II, MQ, DR)
C
ollagen crosslinking can improve corneal rigidity by
increasing bonds between fibers.
L
amellar keratoplasty using DALK techniques
can be considered for progressive keratoconus
without significant scarring or hydrops. (II++, MQ, DR)
Crescentic lamellar keratoplasty is an option when
maximal thinning is in the corneas periphery. (III, IQ,
DR)
P
eripheral thinning and ectasia can be managed
by a standard decentered lamellar procedure for
tectonic support, followed by a central penetrating
keratoplasty later. (III, IQ, DR)
P
enetrating keratoplasty is indicated when a
patient can no longer achieve functional vision with
eyeglasses or contact lenses, or when persistent
corneal edema occurs following hydrops. (III, IQ, DR)
Descemet stripping endothelial keratoplasty cannot
correct ectatic disorder. (III, IQ, DR)
P
enetrating keratoplasty is preferred over DALK in
cases of deep stromal scarring. (III, IQ, DR)
A
lamellar graft can be performed for tectonic
support when ectasia occurs in the far periphery of
the cornea. (III, IQ, DR)
F
ollow-up evaluation and visit intervals are dictated
by treatment and disease progression. (III, IQ, DR)
A
nnual follow up is recommended for cases of
ectasia unless the patient has significant changes in
visual function. (III, IQ, DR)
P
atients should be made aware of the warning
signs of rejection and should seek medical
attention promptly if symptoms occur. (III, GQ, SR)
The practitioner should be aware of the slit-lamp
biomicroscopic findings of epithelial, stromal, and
endothelial rejection. (III, GQ, SR)
Counseling and Referral
W
hen medical therapy with eyeglasses and/or
contact lenses cannot improve visual function, a
referral to an ophthalmologist trained in surgical
treatments for corneal ectasia is indicated (III, GQ, SR)
P
atients with a history of allergy and atopy may
require a referral to a dermatologist or allergist (III,
GQ, SR)
P
atients with floppy eyelid disease may be best
managed by an oculoplastics specialist and referrals
to other medical specialists may also be needed (III,
GQ, SR)
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CORNEA
Corneal Edema and Opacification (Initial Evaluation)
Diagnostic Tests
Symptoms: blurred or variable vision; photophobia;

redness; tearing; intermittent foreign body
sensation; pain
Potential acuity meter
Age of onset
Rapidity of onset
Persistence
Moderating factors, like visual improvement related
to environmental factors
Rigid contact lens overrefraction

Pachymetry
(III, IQ, DR)
Scheimpflug imaging
Specular and confocal microscopy (III, IQ, DR)
Anterior segment optical coherence tomography
(III, IQ, DR)
Ultrasound biomicroscopy
Past ocular and medical history

Topical and systemic medications
Trauma
Contact lens wear
Family and social history
Visual function assessment
- Evidence of proptosis, ptosis, lagophthalmos, or
floppy eyelid syndrome
- Eyelid or facial asymmetry, scarring, and
malfunction
Slit-lamp biomicroscopy (III, IQ, DR)
- Unilateral or bilateral signs
- Diffuse or localized edema
- Primarily epithelial or stromal edema
- Evidence of epithelial breakdown, stromal
infiltration, epithelial ingrowth, striae, focal
thickening, thinning, scarring, interface haze, striae
or inflammation, or stromal vascularization
- Evidence of guttae, Descemets membrane
tear or detachment, endothelial vesicles, keratic
precipitates (KP), pigment peripheral anterior
synechiae
- Involvement of host or donor tissue
- Evidence of sectoral corneal edema and KPs, or
an anterior chamber reaction
- Status, shape, and position of the pupil and iris
- Evidence of vitreous strands or pigment dusting
- Status and position of the lens
IOP measurement
Fundus examination
Gonioscopy
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CORNEA
Corneal Edema and Opacification (Management

Recommendations)
Care Management
Corneal opacification: surgical management
Therapeutic goal is to control the cause of corneal

edema or opacity and enhance a patients quality of
life by improving visual acuity and comfort
- Surgical strategy for managing corneal opacities

depends on the tissue layer(s) involved:
Treatment starts with medical management, but

surgery may be ultimately required
Corneal edema: medical management
- Lowering an elevated IOP is helpful
- Topical carbonic anhydrase inhibitors should
not be the first line of therapy when endothelial
dysfunction is suspected (II, MQ, SR)
- Topical corticosteroid can control inflammation
once infection has been ruled out (III, GQ, SR)
- Microcystic or bullous epithelial disease may
produce discomfort or pain necessitating the
placement of a bandage contact. (III, GQ, SR)
Periodic lens exchange is advised for longer-term
use. (III, IQ, DR)
Corneal edema: surgical management
- Patients with corneal edema and persistent
discomfort, but limited or no visual potential,
are generally better candidates for the following
procedures:
P
hototherapeutic keratectomy
(III, IQ, DR)
C
onjunctival flap of Gunderson (III, IQ, DR)
C
orneal transplantation
E
ndothelial keratoplasty
P
enetrating keratoplasty (III, GQ, SR)
Corneal opacification: medical management
- Corneal opacity treatment can be divided into
two phases: a) management of the principal,
initiating process (i.e., infection, trauma), and
b) management of the resulting problems (i.e.,
surface erosions and irregularity, scarring, thinning,
and vascularization)
- Conventional treatment involves an antibiotic drop
or ointment to protect against secondary bacterial
infection (III, IQ, DR)
- Temporary glue, suture tarsorraphy, or lid splints
can be helpful when blinking or lid closure is
inadequate (III, IQ, DR)
- A bandage contact lens may be useful in cases of
delayed healing (III, GQ, SR)
- A rigid gas permeable lens or hybrid or scleral
lens when greater stability is needed will often
improve vision when surface irregularity is a
factor; such lenses may preclude the need for
more invasive procedures (III, IQ, DR)
E
pithelial debridement is most helpful with
lesions anterior to Bowmans layer (III, IQ, DR)
E
thylenediaminetetraacetic acid (EDTA) may be
used to remove calcific band keratopathy (III, IQ,
DR)
M
itomycin-C for subepithelial, Bowmans layer,
and anterior stromal scarring may help in cases
of possible recurrence (III, IQ, DR)
C
orneal tattooing can mask cosmetically
objectionable corneal leukomas
A
nterior corneal lesions, extending beyond
Bowmans layer into the anterior and midstroma, require more extensive treatment,
such as superficial keratectomy, lamellar or
penetrating keratoplasty, and keratoprosthesis (III,
GQ, SR)
In the management of corneal edema, follow up is
essential to monitor endothelial dysfunction
In the management of corneal opacification, follow
up to monitor corneal clarity and surface irregularity
is necessary (III, GQ, SR)
C
oexisting problems, particularly intraocular
inflammation and IOP, need regular reassessment
(III,
GQ, SR)
Counseling and Referral

D
etailed discussion of the causes of edema or
opacity, and various treatment options, is important.
(III, GQ, SR)
R
eferral to a corneal subspecialist is recommended
when sophisticated diagnostic or medical
management approaches are required (i.e., in cases
exceeding the training of the treating physician).
(III, GQ, SR) Referrals to retina, glaucoma, or pediatric
ophthalmic subspecialists may also be needed. (III,
GQ, SR) Once the condition has been resolved, or
has stabilized, referral back to the comprehensive
ophthalmologist is appropriate. (III, GQ, SR)
W
hen the disease process or management is
complex, every effort should be made to counsel
the patient regarding such challenges to allow for
appropriate expectations and informed decisionmaking. (III, GQ, SR)
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CORNEA
Dry Eye Syndrome (Initial Evaluation)

Ocular symptoms and signs (e.g., irritation, tearing,
burning, stinging, dry or foreign body sensation,
mild itching, photophobia, blurry vision, contact
lens intolerance, redness, mucous discharge,
increased frequency of blinking, eye fatigue, diurnal
fluctuation, symptoms that worsen later in the day)
(III, GQ, SR)
Exacerbating conditions (e.g., wind, air travel,

decreased humidity, prolonged visual efforts
associated with decreased blink rate such as reading
and computer use) (III, GQ, SR)
Duration of symptoms (III, GQ, SR)
Ocular history, including
- Topical medications used and their effect on
symptoms (e.g., artificial tears, eyewash,
antihistamines, glaucoma medications,
vasoconstrictors, corticosteroids, homeopathic or
herbal preparations) (III, GQ, SR)
- Contact lens wear, schedule and care (III, GQ, SR)
- Allergic conjunctivitis (III, GQ, SR)
- Ocular surgical history (e.g., prior keratoplasty,
cataract surgery, keratorefractive surgery) (III, GQ,
SR)
- Ocular surface disease (e.g., herpes simplex virus,

varicella zoster virus, ocular mucous membrane
pemphigoid, Stevens-Johnson syndrome, aniridia,
graft-versus-host disease) (III, GQ, SR)
- Punctal surgery (III, GQ, SR)
- Eyelid surgery (e.g. prior ptosis repair,
blepharoplasty, entropion/ectropion repair) (III, GQ,
SR)
- Bell palsy (III, GQ, SR)

Medical history, including
- Smoking or exposure to second-hand smoke
(II+, GQ, SR)
- Dermatological diseases (e.g., rosacea, psoriasis)

(II++, GQ, SR)
- Technique and frequency of facial washing

including eyelid and eyelash hygiene (II++, GQ, SR)
- Atopy (II++, GQ, SR)
- Menopause (II++, GQ, SR)
- Systemic inflammatory diseases (e.g., Sjgren
syndrome, graft-versus-host disease, rheumatoid
arthritis, systemic lupus erythematosus,
scleroderma) (II++, GQ, SR)
- Other systemic conditions (e.g., lymphoma,
sarcoidosis) (II++, GQ, SR)
- Systemic medications (e.g., antihistamines,
diuretics, hormones and hormonal antagonists,
antidepressants, cardiac antiarrhythmic drugs,
isotretinoin, diphenoxylate/atropine, betaadrenergic antagonists, chemotherapy agents, any
other drug with anticholinergic effects) (II++, GQ, SR)
- Trauma (e.g., mechanical, chemical, thermal)
(II++, GQ, SR)
- Chronic viral infections (e.g., hepatitis C, human

immunodeficiency virus) (II++, GQ, SR)
- Nonocular surgery (e.g., bone marrow transplant,

head and neck surgery, trigeminal neuralgia
surgery) (II++, GQ, SR)
- Radiation of orbit (II++, GQ, SR)
- Neurological conditions (e.g., Parkinson disease,
Bell palsy, Riley-Day syndrome, trigeminal neuralgia) (II++, GQ, SR)
- Dry mouth, dental cavities, oral ulcers (II++, GQ, SR)
- Fatigue (II++, GQ, SR)
- Joint pain, muscle aches (II++, GQ, SR)
Visual acuity
- Skin (e.g., scleroderma, facial changes consistent
with rosacea, seborrhea)
- Eyelids (incomplete closure/malposition,
incomplete or infrequent blink, eyelid lag,
erythema of eyelid margins, abnormal deposits or
secretions, entropion, ectropion)
- Adnexa (enlargement of the lacrimal glands)
- Proptosis
- Cranial nerve function (e.g., cranial nerve V
[trigeminal], cranial nerve VII [facial])
- Hands (joint deformities characteristic of
rheumatoid arthritis, Raynaud phenomenon,
splinter hemorrhage underneath nails)
- Tear film (height of the meniscus, debris, increased
viscosity, mucus strands, and foam break-up time
and pattern)
- Eyelashes (trichiasis, distichiasis, madarosis,
deposits)
- Anterior and posterior eyelid margins
(abnormalities of meibomian glands [e.g., orifice
metaplasia, reduced expressible meibum, atrophy],
character of meibomian gland secretions [e.g.,
turbid, thickened, foamy, deficient], vascularization
crossing the mucocutaneous junction,
keratinization, scarring
- Puncta (patency, position, presence, and position
of plugs)
- Inferior fornix and tarsal conjunctiva (e.g., mucous
threads, scarring, erythema, papillary reaction,
follicle enlargement, keratinization, foreshortening,
symblepharon)
- Bulbar conjunctiva (e.g., punctate staining with
rose bengal, lissamine green, or fluorescein
dyes; hyperemia; localized drying; keratinization,
chemosis, chalosis, follicles)
- Cornea (localized interpalpebral drying, punctate
epithelial erosions, punctate staining with rose
bengal or fluorescein dyes, filaments, epithelial
defects, basement membrane irregularities,
mucous plaques, keratinization, pannus
formation, thinning, infiltrates, ulceration, scarring,
neovascularization, evidence of corneal or
refractive surgery)
October 2016
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26
CORNEA
Dry Eye Syndrome (Management Recommendations)
Care Management
Patient Education
Treat any causative factors that are amenable to

treatment as patients with dry eye symptoms often
have many contributory factors
Counsel patients about the chronic nature of dry

eye and its natural history. (III, GQ, SR)
Sequence and combination of therapies is

determined based on the patients needs and
preferences and
the treating ophthalmologists medical judgment
Provide specific instructions for therapeutic regimens.

(III, GQ, SR)
Reassess periodically the patients compliance and

understanding of the disease, risks for associated
structural changes and realistic expectations for
effective management, and reinforce education. (III,
(III, GQ, SR)
For mild dry eye, the following measures are

appropriate:
GQ, SR)
Refer patients with manifestation of a systemic

disease to an appropriate medical specialist. (III, GQ,
- Education and environmental modifications

(III, GQ, SR)
SR)
- Elimination of offending topical or systemic

medications (III, IQ, DR)
Caution patients with pre-existing dry eye that

keratorefractive surgery, particularly LASIK, may
worsen their dry eye condition. (III, GQ, SR)
- Aqueous enhancement using artificial tear

substitutes, gels/ointments (III, IQ, DR)
- Eyelid therapy (warm compresses and eyelid
hygiene) (III, IQ, DR)
- Treatment of contributing ocular factors such as
blepharitis or meibomianitis (II++, GQ, DR)
- Correction of eyelid abnormalities (II++, MQ, DR)
For moderate dry eye, in addition to above
treatments, the following measures are appropriate:
- Anti-inflammatory agents (topical cyclosporine
and corticosteroids, systemic omega-3 fatty acids
supplements)
- Punctal plugs
(I++, GQ, SR)
- Spectacle side shields and moisture chambers

(III, GQ, SR)
For severe dry eye, in addition to above treatments,

the following measures are appropriate:
- Systemic cholinergic agonists
- Systemic anti-inflammatory agents
- Mucolytic agents (III, IQ, DR)
- Autologous serum tears
- Contact lenses
- Correction of eyelid abnormalities
- Permanent punctal occlusion
(III, IQ, DR)
- Tarsorrhaphy (III, IQ, DR)

Monitor patients prescribed corticosteroids for
adverse effects such as increased intraocular
pressure, corneal melting, and cataract formation
(III,
GQ, SR)
October 2016
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PEDIATRICS
Amblyopia (Initial and Follow-up Evaluation)
Ocular symptoms and signs
Follow-up visits should include:
[A:III]
Ocular history [A:III]
- Interval history
Systemic history, including review of prenatal, peri

natal, and postnatal medical factors [A:III]
- Adherence to treatment plan

- Side effects of treatment
[A:III]
Family history, including eye conditions and relevant

systemic diseases [A:III]
- Visual acuity of each eye
[A:III]

Assessment of fixation pattern and visual acuity
Binocular alignment and ocular motility
Binocular red reflex (Brckner) test
Pupillary examination
[A:III]
[A:III]
[A:III]
[A:III]
[A:III]
Anterior segment examination

Funduscopic examination
[A:III]
Follow-up examination generally arranged 2 to

3 months after initiation of treatment [A:III]
Timing varies according to intensity of treatment
and age of child [A:III]
Continued monitoring required because about onefourth of children successfully treated experience a
recurrence within the first year after treatment has
stopped [A:III]
Patient Education
[A:III]
Cycloplegic retinoscopy/refraction
[A:III]
[A:III]
[A:III]
Care Management
All children with amblyopia should be offered an
attempt at treatment regardless of age [A:III]
Discuss diagnosis, severity of disease, prognosis

and treatment plan with patient, parents and/or
caregivers [A:III]
Explain the disorder and recruit the family in a
collaborative approach to therapy [A:III]
Choose treatment based on patients age; visual

acuity; adherence with previous treatment; and
physical, social, and psychological status [A:III]
Treatment goal is equal visual acuity between the
two eyes [A:III]
Once maximal visual acuity has been obtained,
treatment should be tapered and eventually
stopped [A:III]
October 2016
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PEDIATRICS
Esotropia (Initial and Follow-up Evaluation)
Periodic evaluations necessary because of risk of

developing amblyopia losing binocular vision, and
recurrence [A:II]
[A:III]
Ocular history (date of onset and frequency of the

deviation, presence or absence of diplopia) [A:III]
Systemic history (review of prenatal, perinatal and
postnatal medical factors) [A:III]
Children who are well-aligned and do not have

amblyopia may be followed every 4 to 6 months
Family history (strabismus, amblyopia, type of

eyeglasses and history of wear, extraocular muscle
surgery, genetic diseases) [A:III]
Frequency of follow-up visits can be reduced as

child matures [A:II]
Hyperopia should be assessed at least annually

and more frequently if visual acuity decreases or
esotropia increases [A:III]
Fixation pattern and visual acuity
[A:III]
Binocular alignment (at distance and near)

Extraocular muscle function
[A:III]
[A:III]
Monocular and binocular optokinetic nystagmus

testing for nasal-temporal pursuit asymmetry [A:III]
Detection of latent or manifest nystagmus
New or changing findings may indicate need for

more frequent follow-up examinations [A:III]
Repeat cyclopegic refraction is indicated when

esotropia does not respond to initial prescription
of hyperopic refraction or when esotropia recurs
after surgery [A:II]
[A:III]
Sensory testing [A:III]

Cycloplegic retinoscopy/refraction
[A:III]
[A:III]
Fundoscopic examination [A:III]

Care Management
Consider all forms of esotropia for treatment and
re-establish ocular alignment as soon as possible [A:III]
Patient Education
Discuss findings with the patient when
appropriate and/or parents/caregivers to enhance
understanding of disorder and to recruit them in a
collaborative approach to therapy [A:III]
Formulate treatment plans in consultation with
the patient and/or family/caregivers [A:III]
Prescribe corrective lenses for any clinically

significant refractive error [A:I]
If eyeglasses and amblyopia management are ineffective in aligning the eyes, then surgical correction
is indicated [A:III]
Start amblyopia treatment before surgery to alter
angle of strabismus and/or increase likelihood of
binocularity [A:III]
October 2016
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PEDIATRICS
Exotropia (Initial and Follow-up Evaluation)
Follow-up Evaluation
Frequency of follow-up evaluations is based on age

of child, ability to obtain an accurate visual acuity,
and control of the deviation [A:III]
[A:III]
Ocular history (date of onset and frequency of the

deviation, presence or absence of diplopia) [A:III]
Systemic history (review of prenatal, perinatal and
postnatal medical factors) [A:III]
Family history (strabismus, amblyopia, type of
eyeglasses and history of wear, extraocular muscle
surgery, genetic diseases) [A:III]
Fixation pattern and visual acuity
[A:III]
Binocular alignment (at distance and near)

Extraocular muscle function
[A:III]
Detection of latent or manifest nystagmus

Sensory testing
[A:III]
[A:III]
[A:III]
Cycloplegic retinoscopy/refraction [A:III]

Fundoscopic examination [A:III]
Children with good fusional control of intermittent

exotropia and without amblyopia are typically
examined every 6 to 12 months [A:III]
Intervals are reduced once visual maturity is reached
[A:III]
Includes interval history, adherence to treatment

(if any), and assessment of ocular motility [A:III]
Patient Education
Discuss findings with the patient when appropriate
and/or parents/caregivers to enhance understanding
of disorder and recruit them in a collaborative
approach to therapy [A:III]
Formulate treatment plans in consultation with the
patient and/or family/caregivers [A:III]
Care Management
All forms of exotropia should be monitored and
some will require treatment [A:III]
Young children with intermittent exotropia and good
fusional control can be followed without surgery [A:II]
Deviations that are present most or all of the time
require treatment [A:III]
Prescribe corrective lenses for any clinically
significant refractive error [A:III]
Optimal modes of therapy are not well established
October 2016
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30
Keratorefractive Surgery (Initial and Follow-up Evaluation)

Present status of visual function
Ocular history
Medications
Patient Education
Discuss the risks and benefits of the planned
procedure with the patient. [A:III] Elements of the
discussion include the following:
[A:III]
[A:III]
Systemic history
REFRACTIVE
[A:III]
Range of expected refractive outcomes
[A:III]
Residual refractive error
Reading and/or distance correction postoperatively
Distance visual acuity with and without correction
Loss of best-corrected visual acuity
[A:III]
Manifest, and when appropriate, cycloplegic refraction [A:III]

Computerized corneal topography
[A:III]
Central corneal thickness measurement
[A:III]
Evaluation of tear film and ocular surface
[A:III]
Evaluation of ocular motility and alignment
[A:III]
Care Management
Side effects and complications (e.g., microbial

keratitis, sterile keratitis, keratectasia)
Changes in visual function not necessarily measured
by visual acuity testing, including glare and function
under low-light conditions
Night vision symptoms (e.g., glare, haloes)
developing or worsening; careful consideration
should be given to this issue for patients with high
degrees of ametropia or for individuals who require
a high level of visual function in low-light conditions
Discontinue contact lenses before preoperative

exam and procedure [A:III]
Effect on ocular alignment
Inform patient of the potential risks, benefits, and

alternatives to and among the different refractive
procedures [A:III]
Recurrent erosion syndrome
Document informed consent process; patient should

be given an opportunity to have all questions
answered before surgery [A:III]
Check and calibrate instrumentation before the
procedure [A:III]
Surgeon confirms the identity of the patient, the
operative eye, and that the parameters are correctly
entered into the lasers computer [A:III]
Postoperative Care
Operating surgeon is responsible for postoperative
management [A:III]
For surface ablation techniques, examination on the
day following surgery is advisable and every 2 to
3 days thereafter until the epithelium is healed [A:III]
For uncomplicated LASIK, examine within 36 hours
following surgery, a second visit 1 to 4 weeks post
operatively, and further visits thereafter as appropriate [A:III]
Dry eye symptoms developing or worsening

The limitations of keratorefractive surgery with
respect to presbyopia and the potential loss of
uncorrected near visual function that accompanies
myopia correction
Monovision advantages and disadvantages (for
patients of presbyopic age)
Conventional and advanced ablations advantages
and disadvantages
Advantages and disadvantages of same-day
bilateral keratorefractive surgery versus sequential
surgery. Because vision might be poor for some
time after bilateral same-day photorefractive
keratectomy, the patient should be informed that
activities such as driving might not be possible for
weeks.
May influence predictive accuracy of IOL
calculations for subsequent cataract surgery
Postoperative care plans (setting of care, providers
of care)
October 2016
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SUMMARY BENCHMARKS FOR PREFERRED

PRACTICE PATTERN GUIDELINES

SUMMARY BENCHMARKS FOR

Cochrane Library for articles in the English language

SUMMARY BENCHMARKS FOR

2016 American Academy of Ophthalmology

Level I includes evidence obtained from at least

Primary Open-Angle Glaucoma (Initial Evaluation)

Initial Exam History (Key elements)

Examination of optic nerve head appearance by

Laser trabeculoplasty can be considered as initial

Trabeculectomy is effective in lowering IOP; it is gen

Surgery and Postoperative Care for Laser

Primary Open-Angle Glaucoma (Follow-up Evaluation)

Reassess treatment regimen if target IOP is not

Interval ocular history

Adjust target pressure downward if optic disc, retinal

Approximate Follow-up Interval

IOP = intraocular pressure; NA = not applicable

2016 American Academy of Ophthalmology

Primary Open-Angle Glaucoma Suspect (Initial and

Follow-up Exam History

Interval ocular history

Interval systemic medical history and any change of

Side effects of ocular medications if patient is being

Frequency and time of last glaucoma medications,

Initial Physical Exam (Key elements)

Follow-up Physical Exam

Visual acuity measurement

If visual field glaucomatous damage is newly

2016 American Academy of Ophthalmology

Primary Angle Closure (Initial Evaluation and Therapy)

Initial Exam History (Key elements)

Perform prophylactic iridotomy in fellow eye if

Surgery and Postoperative Care for Iridotomy

Patients should be informed about the symptoms of

2016 American Academy of Ophthalmology

Age-Related Macular Degeneration (Initial and

Medications and nutritional supplements (II+, GQ, SR)

Social history, especially smoking (III, GQ, SR)

2016 American Academy of Ophthalmology

Changes in medications and nutritional supplements

Changes in ocular history and systemic history

Changes in social history, especially smoking (III, GQ, SR)

Follow-up after Treatment for Neovascular AMD

Age-Related Macular Degeneration (Management

Diagnoses Eligible for Treatment

Observation with no medical or

No clinical signs of AMD (AREDS category

As recommended in the Comprehensive Adult Medical Eye

Early AMD (AREDS category 2)

Return exam at 6 to 24 months if asymptomatic or prompt

Advanced AMD with bilateral subfoveal

Return exam at 6 to 24 months if asymptomatic or prompt

Antioxidant vitamin and mineral

Intermediate AMD (AREDS category 3)

Monitoring of monocular near vision (reading/Amsler grid)

Advanced AMD in one eye (AREDS

Return exam at 6 to 18 months if asymptomatic or prompt

Aflibercept intravitreal injection

Fundus photography and/or fundus autofluorescence as

Bevacizumab intravitreal injection

The ophthalmologist should

Reassess treatment regimen if target IOP is not

Interval ocular history

Adjust target pressure downward if optic disc, retinal

Interval ocular history

Interval systemic medical history and any change of

Side effects of ocular medications if patient is being

Frequency and time of last glaucoma medications,

Patients should be informed about the symptoms of

Medications and nutritional supplements (II+, GQ, SR)

Social history, especially smoking (III, GQ, SR)

Changes in medications and nutritional supplements

Changes in ocular history and systemic history

Changes in social history, especially smoking (III, GQ, SR)

Duration of diabetes (II++, GQ, SR)

Optical coherence tomography can be used to

Past glycemic control (hemoglobin A1c) (II++, GQ, SR)

Ocular history (III, GQ, SR)

Gonioscopy before dilation when indicated (for

Pupillary assessment for optic nerve dysfunction

Glycemic status (hemoglobin A1c)

Visual acuity (III, GQ, SR)

Slit-lamp biomicroscopy with iris examination

Gonioscopy (preferably before dilation when iris

Stereoscopic examination of the posterior pole after

Fluorescein angiography is not routinely indicated

Inform patients that effective treatment for diabetic

OCT imaging when appropriate

Fluorescein angiography is used as a guide for laser

Systemic status (pregnancy, blood pressure, serum

Fundus photography may be useful for

Communicate with the attending physician, e.g.,

Visual acuity (III, GQ, SR)

Ocular history: glaucoma, retinal detachment or tear,

Slit-lamp biomicroscopic examination of the macula

Medications that may be related to macular cystoid

Indirect peripheral retinal examination

Frequency and timing of subsequent visits varies depending on the